Independence Day in Montevideo!

July 4, 2012

It’s July 4th and it’s raining steadily and is about 45 degrees. We’ve had a free travel weekend, turned in term papers and taken final exams in the past 5 days. Look at your favorite student’s Facebook page to learn more about their free travel weekend.

Today is our second-to-last day in Montevideo and the final day of shadowing at Escuela Roosevelt and Hospital de Clinicas. We took gifts of thanks to our hosts at each location with carefully written letters. (It’s surprising how long it can take to hand write a letter in a language that’s not your first language…even if someone else does all the translating for you!) This has been an excellent opportunity for our students. You will see more photos from the Escuela Roosevelt because they have signed releases to allow photos of their students. At the hospital we are very careful not to violate any patient’s privacy, so we have taken only a few photos with the physicians and professors who have been so gracious and allowed our students to follow them on their rounds and or observe surgeries. It’s interesting because each of the physicians asked us to please email a copy of the photographs we took. They seem to have enjoyed having our students and teaching them a little about the practice of medicine in the Uruguay. Our students have observed discussions of complicated cases, insertion of stints and other heart procedures, patient evaluations, patients being bathed and cared for in other ways. We are very impressed with the personal concern shown by Uruguayan physicians and nurses who know their patients well and place high value on strong relationships between patient and professional staff.

Students with Dr. Sosa, Dr. Perazza and Dr. Powell on the Internal Medicine floor.

Dr. Perazza and the Professor of Cardiology with three students and Dr. Powell.

I’ve asked each of the students to post a comment after this post that is a reflection on what they’ve observed and learned about the influence of culture on the practice of medicine in Uruguay. We are grateful to have had this experience and will miss the students and faculty who have become our Casa ACU family.

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My time here in Uruguay has shown me many of the differences between here and America that are not only evident in professional settings, but in the culture as a whole. Perhaps the most prominent of these is the concept of “South American Time.” Life here runs on a much more relaxed schedule with no particular rush to get anywhere or get anything done quickly. Society is centered around relationships, and it is not uncommon to drop everything and take a moment to have a conversation with someone. In our experiences at Hospital de Clinicas, every morning we arrived included pausing for the customary time of greeting and small talk when we met the doctors. Every time. This was a lesson in patience, but I was surprised that everything still gets done. It may take longer, but everything still gets finished in a somewhat timely manner, and with quality results. Also at Clinicas, I found it especially interesting to observe the relationships between the doctors and the patients. These were not merely about the physical ailment of the patient, but developing a real relationship with the person behind the illness. Instead of just delivering the medicine or diagnosis, the doctors spent time with each patient and took time to know about them and their life. They asked about kids and grandkids, and talked to each other like friends. I was also surprised by how much time the doctors spent with each individual patient. Often in America, people only get about five minutes of the doctor’s time, but here the usual time was at least thirty minutes with each person. This included not only a verbal examination, but also a full body test to make sure that no symptom had been overlooked. I think that this type of time spent on the patient is something that the United States healthcare system would do well to imitate. It develops a more intimate relationship between the healthcare provider and the patient, which builds more trust. The patient feels more comfortable talking to the doctor, and the doctor is able to make a more accurate diagnosis of the patient, as well as monitor any improvements. Overall, my time here in South America has given me a number of invaluable experiences, and I have learned not only about healthcare, but also about truly caring for people.

Instead of going to Hospital de Clinicas, Josh and I visited the Uruguayan office for Johnson and Johnson and the local Coca Cola factory (thanks to Rosalinda’s hard work in arranging both visits!). As business students, we thought observing how American businesses operate in Uruguay would be informative, and both visits proved very helpful in understanding some of the complexities of international business.

Before going to the Johnson and Johnson office, Josh and I did a bit of research about J&J products. Not only does the company sell consumers products, but they also sell pharmaceuticals and medical equipment. The J&J office we visited here manages the consumer products division. Our questions mainly focused on how a company as large as J&J communicates with regional offices in different countries. We learned that all employees in Uruguay must have a basic knowledge of English in addition to Spanish, the office communicates every day with headquarters in the US through email and conference calls, a J&J employee travels to Uruguay every year or so to monitor the office, and reports are due often. We did not stay long enough to get a thorough view of Uruguayan culture in an American company, but the company is focused on relationships with its employees, which in my experience reflects the emphasis on relationships in Uruguayan society. J&J provides many amenities for their office employees such as free meals, and the woman who spoke with us advised Josh and I to always cooperate and respect other people.

Our visit to the Coke factory was a little different, as we did not have as much time or the chance to walk around the factory. What made an impression on me, though, were the differences in Coke products around the world and the advice our contact gave us. First, Coke offers over two hundred different types of drinks depending on the region of the world. In Uruguay, they apparently have a market for fruity drinks along with regular and diet Coke. Second, when asked for advice, our contact said that managing people is learned, not a skill only some people possess. Even in international business, we can learn how to relate and work with people.

I am very grateful that Josh and I had the opportunity to get a look at international American companies, and I am equally grateful for the kindness our Uruguayan contacts showed us.

A few particular aspects of Uruguayan culture, as demonstrated through interactions observed between medical professionals at the Hospital de Niños Perreira Rossel, have stuck out the most to me. One thing I observed was collaboration. The professionals believe very strongly in teamwork methods and rarely fail to involve multiple people during treatment of a patient. The aspects of Uruguayan culture that can be seen through this are collectivism and unity. Latin American cultures generally tend to be more collectivistic, and this is seen in the collaboration of the medical professionals. Uruguayans have also told me about how they feel their country has a sense of unity because it is so small. There was definitely a sense of togetherness in the hospital as the groups of professionals worked with each patient. The second thing I observed was the relaxed pace taken on by medical professions when treating patients; they did not concern themselves with keeping appointments quick and short, and clearly did not base their level of efficiency on how much time each visit took. This behavior reflects the idea of Uruguayan culture being more event-oriented, whereas the U.S. is more time-oriented. For the people of Uruguay, as well as most Latin American cultures, the most important thing is not timeliness or efficiency. They focus more on the current activity and its importance, and one could argue that (at least in some ways) it is a “quality over quantity” mindset. All of these aspects of Uruguayan culture—the collectivism and unity versus the individualism found in the U.S., and the event orientation versus time orientation—have great value. While one could argue that so much collaboration between medical professionals along with such a relaxed time pace is less efficient, there is something to be said for the quality of service that is being provided by these public health facilities to each patient. Even with our cutting-edge research, high-tech equipment and fancy facilities, medical professionals in the U.S. can still take away valuable aspects of health care services being provided in the tiny country of Uruguay.

Over the past six weeks, I have gotten the chance to see the difference in interactions between doctors and patients that exists here in Uruguay as opposed to the United States. In the United States, physicians for the most part seem to be task-driven individuals who concentrate on treating the ailment of the patient and are concerned less with the doctor-patient interaction. However, medicine in Uruguay is defined by relationship, and physicians seem to be much more interested in the relationship they form with their patients. This may be due to the Uruguayan culture in general: one that is focused on interaction with people.

Specifically I have spent time with medical school students that are going through the process of clinical testing. This involves an initial diagnosis with a patient followed by a presentation to other students discussing the causes of the disease and the treatment. The diagnosis consists of a series of questions to the patient in order to determine the causes of the ailment and is followed by a physical examination. Although this may seem routine for any medical treatment, the difference lies in the questions asked and the relationship formed between the patient and the doctor. The doctor seemed to take an interest in the patient’s life and asked about things other than medicine. In addition, they always put themselves on the patient’s level and talked to them as two friends would. I believe the reasoning for this lies in the nature of the Uruguayan culture. The Uruguayan people focus on relationships and will stop whatever they are doing to talk to a friend or even a stranger. This society places less emphasis on time management and more on maintaining relationships with people. Because of this, the physicians here form meaningful relationships with their patients.

This is one area where I believe the United States could improve. As a student with aspirations to become a doctor, I want to adopt these practices by placing more emphasis on people. I think it is important to remember that life is about relationships, not simply the accomplishments you make. I hope that I will be able to emulate the Uruguayan culture and can become the kind of doctor that takes an interest in each patient’s life.

Every week for about the last month and a half, I have been able to observe the workings of multiple departments at the Hospital de Clinicas in Montevideo. Specifically, I have spent most of my time in either the cardiology department or with a small group of medical students who present one patient to their professor. I have also been lucky to see parts of the emergency, pediatric, and gynecology departments.

One of the first things that I noticed about medical professionals at the hospital is that they interact with each other in very laid back and informal ways. For the most part, Hospital de Clinicas is a very low-stress environment (even in the emergency room). My time shadowing the medical students was full of jocular and informal exchanges between them and their professor, Dr. Sosa. One morning as I was observing a pacemaker implant in the cardiology department, one of the lab techs passed me a mate, a green tea-like beverage that is nothing short of a necessity for the Uruguayan citizen. This naturally made me feel very welcome to the group, and this familiarity really epitomizes the laid-back and inclusive nature of medicine in Uruguay.

I don’t think this is exclusive to medicine here though; on the contrary, I think that the informal and friendly mindset is a product of the bigger social picture of the country. I struggled to see examples of personal pride on this trip. The first night that we went out to dinner without a translator, we stumbled through our orders and I was waiting for the waiter to get impatient. However, he was very gracious and helped us break through the language barrier. While America has basic luxuries like free refills and free water with your meal, I was much more impressed with the quiet patience and accommodating nature of the service personnel in Uruguay. This, in my opinion, reflects the emphasis that many Uruguayans place on interpersonal relationships, and I will definitely bring that mindset back to the USA with me.

Through my six weeks of shadowing at the Hospital de Clinicas, I have observed that the health care system of Uruguay places a strong emphasis on personal relationships. Even in the professional setting of a hospital doctors would great each other with a kiss on the cheek. The doctors also try to form a relationship with their patients because they believe that it will help their treatment. Some of the patients that we saw at Hospital de Clinicas had been patients there for an extended period of time and the doctors knew these patients very well. The doctors that we shadowed also showed that they appreciated the relationships that they formed with us over the course of six weeks. On our last week of shadowing one doctor, Dr. Sosa, exchanged his email with us and encouraged us to write him.

I think that the importance of relationships that is seen in the hospitals is a reflection of the value of relationships in the Uruguayan culture. The value of relationships was evident when we attended church in Uruguay and received a kiss on the cheek from every member of the congregation because they considered us a part of their family the moment we walked into the church doors. Another aspect of the Uruguayan culture that was evident in the workings of the hospital was their laid back attitudes. No one ever seems to be in a hurry in Uruguay and that was true in Hospital de Clinicas as well. Many of the patients had been in the hospital for over a month because of the slow process of treatment. The laid back attitude was also visible in the doctor’s examinations of the patients. The examinations would be as long as thirty minutes of one-on-one time with the patient.

The US health care system could learn from the Uruguayan health care system about how to form doctor-patient relationships. I observed how the formation of relationships could improve the care of the patient. By forming a relationship with their patients doctors are better able to evaluate the needs of the patients.

Having the opportunity to physically observe how Uruguayan doctors and their patients interact was an experience that I will never forget. At Hospital de Clinicas, everything moves at a slow pace, similar to the pace of the Uruguayan culture. This slow pace is discouraging for many patients because they have to wait for days to receive lab results and x-rays. Doctors not only invest their time into developing a relationship with each patient, but they also provide excellent care given the limited resources available.

One observation day I had the opportunity to see a spinal tap on a man who was HIV positive. This is a very painful procedure involving a large needle being inserted into the spinal cord to collect spinal fluid. Since Hospital de Clinicas is a teaching hospital, the head doctor guided the student who performed the minor operation as a teaching technique. When the patient screamed out in pain, the head doctor immediately turned his focus to help him stay still. The doctor let the patient place his head on him for comfort since he had no family there for support. This act of friendship between the doctor and patient provided comfort for the patient during this painful moment. A major difference between Uruguay and the US is shown through the Uruguayan doctors investing their time into each individual patient. The US doctors tend to see their job as a quick fix for a patient and that’s it, but in Uruguay, it is customary to sit around and talk for awhile and develop a friendship with their patients.

One aspect of the Uruguayan culture worthy of imitation is to be more relational with patients. Being a nurse will require me to not only care for health, but also care for emotional experiences of my patients and comfort them during their pain. Another aspect that I see important is to view each patient without judgment. The doctor who comforted the man who was HIV positive was not worried about what his medical condition was, he simply acted out of instinct reflecting their culture’s view of relationships between the doctors and patients. The doctor’s only goal was to help that patient get through the spinal tap comfortably. This act of kindness towards the patient inspires me to treat nursing as a service to others simply because we are not there to help ourselves, but help others who need comfort and care.

Every Wednesday for the past six weeks I have walked through the large, decaying doors of Hospital de Clinicas in order to study the way that health care is administered in a country different from my own. This hospital is the main public hospital in the entire country and is located in the heart of Montevideo, Uruguay, so it is not lacking in Uruguayan culture. This cultural surplus became evident to me when Doctora Ponce greeted me on the first day with a big kiss and an even bigger “mucho gusto!” Spending my Wednesdays with her I was exposed to things that I never had been exposed to before. I saw cancer patients treated, listened to heart arrhythmias, looked into the glazed-yellow eyes of a man with Jaundice, and saw the affects of a drug addiction on a teenage boy; to name a few of the things. Through this experience I found that the impassioned greeting I received when I first met Doctora Ponce was not only the way that she interacted with awkward Americans who know little Spanish; she treated each and every one of her patients with the same genuine interest and love.

I vividly remember walking into room 3 on about the third Wednesday of my shadowing experience to see a 64-year-old man suffering from colon cancer lying in a hospital bed with desperation in his eyes. He had apparently been in the hospital for an extended period of time because Doctora Ponce seemed to know him very well. She started to tell him how imperative it was for him to eat something in order to keep up his strength. As tears began to flood his despair-filled eyes he repeated the words, “Para que?” (“For what?”) Doctora Ponce slowly lowered herself to sit on the edge of his bed as she put her arms around him and held him until he stopped crying some 5 minutes later. Then she stood up, looked him in the eyes, and said, “come algo” (“eat something”) as we left the room.

This experience and others similar to it gave me an idea of how integral relationships are to the Uruguayan people and to Uruguayan medicine. This is the main aspect of Uruguayan culture that I would like to see more of in American Medicine. It is important to create genuine relationships with your patients in order to treat them most effectively.

While observing in the children’s hospital, I saw so much of the Uruguayan culture coming through the way the doctors interacted with their patients. When we observed the feeding and swallowing section of the hospital, we saw a group of about five doctors work with a single patient at one time. Before they began the appointment, the doctors would go into a separate room and discuss the child’s past medical records together. Then, after being updated on the situation, they go into the room with the patient and greet them like old friends. I could tell from the doctors’ interactions with the child that they truly cared for them and they took the time to ask about their life and what their problems were. The appointment that we sat in on was a least thirty minutes long and they would have gone on even longer if they had needed to because they did not rush through all the questions that they had. During the six weeks that I have been here, it has become very obvious to me that Uruguayans are very community based and do not see a reason to rush anything. This was very apparent in the way that the doctors worked with their patients. They took their time because they were focusing solely on the patient that they were working with at that time. They were not only their doctors but their friends. Uruguayans treat everyone they meet like they are friends, including us. As soon as we came in, we were friends; kissed on the cheek when we walked in and again when we left. The biggest difference that I saw from the American system is the relaxed atmosphere. In America, an appointment is set at a certain time and doesn’t normally last longer than planned. We also only typically see one doctor at that appointment because our philosophy is that the more doctors that are available, the more patients they can see at one time. The fact that they don’t really have a set time for their appointments shows the relaxed atmosphere of their culture in general.

Over the past several weeks I have thoroughly enjoyed learning about the different methods used in the Uruguayan medical systems. I have been shocked by some of the sites I have witnessed. I have noticed many different extremes between the hospitals and clinics here compared to the ones I have always known in the United States. Working in Hospital de Clinicas has been one of the most extreme settings I have been in that I have felt unqualified, yet still given responsibilities. One of the main differences I noticed in these was the lack of privacy shown throughout the entire hospital. I’m assuming it did not bother the patients that were being treated because they did not seem appalled at the fact that a random American stranger was helping their nurses and doctors to treat them and serve them. I know that if I was in their situation I would have felt extremely exposed and vulnerable. In America the doctors are sworn to confidentiality and it is expected to have as much privacy as you would like. There were several times when I was asked to help give elderly or incapable men baths, or change their soiled bedding. I immediately helped in every way they asked me to even though I was feeling kind of out of my element because I had never dealt with those things before, especially when I was concerning patients in a hospital. Another aspect that I noticed was the way that the Uruguayans interacted with others. This culture is so different from ours in the way that people seem to really care to take the time to talk to everyone and enjoy themselves. Everything is more slow paced it seems than in our busy American culture. Doctors are rushing from patient to patient in America, whereas in Uruguay they take the time to really care for the patients. Everyone seemed a bit friendlier, chatting in different circles and sipping on matte in between patients. Overall it was extremely interesting to watch the way that this culture differs from ours back home; and how the doctor to patient interactions varied.

Over our 7-week experience in Uruguay we received the opportunity to shadow at the Hospital de Clinicas as well as visit a couple other healthcare related institutions. The healthcare systems of the United States and Uruguay are similar in many respects, however they also have many differences. In this reflection I will highlight some of the things that really stood out to me in the Uruguayan healthcare system.
South Americans are known for taking their time in every situation; the Uruguayans are no exception. When we first met the doctors and interns we were going to be shadowing with, we took what seemed to us as unnecessarily long amount of time making small talk. Though this seemed unnecessary what I began to see when I continued my shadowing experience was that this pattern continued over to the patients. Doctors did not rush through their rounds but spent a lot of time caring for every need of the patient and attempting to look at the case through all angles.
Montevideo is filthy. There is trash and debris littering the streets. It is a city in decline. However, the people that I have come into contact have been so willing to help and serve me as I attempted to stumble around the city with minimal English. Hospital de Clinicas is in decline as well. The walls are crumbling and lined with mold. The equipment that they are sometimes required to use is crude and half-broken. The people that serve in Hospital de Clinicas are dedicated servants of the people as they tirelessly serve the sick of their nation, even though the facilities they use are degenerating.
I think that though many people in the United States boast having the best equipment and the best medicines there are a few things that we could take from the Uruguayans. Doctors from the United States attempt to speed through their patient list as quick as possible, I think that the Uruguayan system of taking time with patients shows a much greater care for the patient and will overall help cure the patient more adequately. Though the hospitals of United States have the best equipment, the Uruguayans have shown that it is not just the equipment that heals a person but a caring person willing to take the time to address the needs of patients. I think the United States healthcare system would dramatically improve if they took these two notes from the Uruguayan system.

In the past few weeks we’ve spent observing at the Hospital de Niños Perreira Rosse and other medical facilities, there are some characteristics in medical professions that differ from the United States. One difference that I was most impressed with was the early exposure to clients, assessments, and therapy work for the students of this field. Working side by side with their teachers gave them a great opportunity to see an experienced approach to a particular problem, as well as test out her own perspective. I also value this characteristic because a student will realize very quickly if this is the line of work they would like to pursue.
Another difference is the time spent with each client. Rather than spreading out personnel to attend to more clients, several professionals were available to each individual patient. This kind of collaboration provides a calm atmosphere for visitation without rushing, and creates the environment needed to get know the client on a personal level. It was surprising and refreshing to see the kids interact with their doctors as if they were family. The openness with family, and friends for that matter, is a an important concept in Uruguay.
One other aspect I noticed is determination, although I would not consider the aspect itself a difference, but I would say so about the approach. In several medical facilities and schools throughout Uruguay, it was very humbling to see the lack of technology. In the back of mind I’m wondering how they get anything done without the equipment that is so readily available in the States? They make due by their willingness to do things that medical professionals in the U.S. don’t do because of either a restriction or it’s just no longer common. “If they can’t come to us, then we will go to them,” is what the director of Hospital de Clinicas informed us on our tour. There are so many sad stories from the U. S. about people who cannot get medical help because of transportation issues. But these professionals willing take on the responsibility to make sure all of their patients always have access to medical care. I believe that is admirable in the medical field.

It was interesting to observe how the doctors in Uruguay interacted so differently with their patients and with their fellow medical care professionals. The Speech-Language Pathology students went to observe at a children’s hospital while in Uruguay and we got to sit in on a couple of consultations and therapy sessions. During the consultations we observed that there would be three or four different types of doctors all in one appointment with a patient. Before the appointment all of the doctors would have a meeting and discuss their patients medical history and also what they wanted to discuss during the appointment.
The health care professionals were on a very personal level with their patients. They would spend the first part of their appointments talking with the patients and asking them how they were doing. There was one instance when one of the doctors asked the patient if he still watched SpongeBob Square pants with his sister. I think that is amazing that the doctors take the time to be on such a personal level with each patient, and they take time to show the patient they truly care. Unlike most medical professionals in the United States that like to make their appointments quick and easy. They like to get people in and out fast so they can see more patients, which then means they get more money.
The way the medical professionals in Uruguay treat their patients is greatly influenced by the Uruguayan culture and the United States could learn a lot from the way they work with their fellow healthcare professionals and their patients. Uruguayan culture is very friendly, patient, and hospitable. And as I said before this carries over to the professional side of how they handle their appointments and the way they practice their medicine. Once I become a certified Speech-Language Pathologist I hope that I can remember how the Uruguayans treated their patients and I hope that I can use what I saw in my practice as I work with patients and alongside other doctors and Speech Pathologists.